Medicine of the older adult: .Prescribing and deprescribing in older people

• Principles: Why Older People Are Vulnerable to Drugs | Kidney Function and Drug Dosing | Polypharmacy | Adverse Drug Reactions and Prescribing Cascades
• Tools and review: STOPP/START and Other Tools | Anticholinergic Burden | Deprescribing | Medication Review, Adherence and Transitions
• Drug groups: Anticoagulation and Antiplatelets | Blood Pressure, Statins and Heart Drugs | Diabetes in Frailty | Pain Relief | Psychotropics and Hypnotics | PPIs, Laxatives and Other Common Drugs | Care Homes and Covert Medication
• Revision: Drugs to Watch in Older People | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Prescribing and deprescribing in older people — page 4 of the Medicine of the Older Person chapter. Older people take the most medicines and suffer the most harm from them — adverse drug reactions cause about 1 in 10 emergency admissions in older people, and many are preventable. Good prescribing means starting low and going slow, reviewing regularly, and having the confidence to stop drugs that no longer help. General pharmacology is in the specialty Anatomy, Physiology and Pharmacology chapters.
Your four questions for every medicine: What is it for — and is that still a problem? Is it helping (or likely to, within this person's life expectancy)? Could it be causing harm (falls, confusion, kidney injury, bleeding)? What does the patient want — and can they take it as prescribed?

Why Older People Are Vulnerable to Drugs

• Pharmacokinetics (what the body does to the drug):
  • Absorption — mostly unchanged (slower gut transit, higher gastric pH).
  • Distribution — less body water (higher levels of water-soluble drugs — digoxin, lithium, gentamicin), more fat (fat-soluble drugs — diazepam — last longer), lower albumin (more free drug — phenytoin, warfarin).
  • Metabolism — reduced liver blood flow and mass — slower clearance of some drugs (e.g. morphine, some benzodiazepines).
  • Excretion — reduced kidney function — the most important change — accumulation of renally cleared drugs (DOACs, metformin, gabapentin, morphine metabolites, digoxin, lithium, allopurinol, aminoglycosides).
• Pharmacodynamics (what the drug does to the body) — increased sensitivity of the brain (sedatives, opioids, anticholinergics — confusion and falls), reduced baroreceptor responses (postural hypotension with antihypertensives), and reduced homeostatic reserve (hyponatraemia, hypoglycaemia, AKI).
• Other factors — multimorbidity, polypharmacy and interactions, cognitive impairment, visual impairment, swallowing problems, poor dexterity, frequent prescribing changes between settings.
• Lack of evidence — trials often excluded older and frail people; benefits seen in younger trial populations may not apply.
• Principle — "start low, go slow" — but do reach effective doses where treatment is worthwhile (under-treatment is also a problem).

Kidney Function and Drug Dosing

• Creatinine depends on muscle mass — in frail older people with little muscle, a "normal" creatinine may hide significantly reduced kidney function.
• eGFR (CKD-EPI) — used for CKD staging; less accurate at extremes of body size.
• Creatinine clearance (Cockcroft–Gault) — uses age, weight, sex and creatinine; recommended for dosing drugs with a narrow therapeutic index and for DOACs, and in people at extremes of weight or aged 75 or over (MHRA, BNF):
  • CrCl (mL/min) = [(140 − age) × weight (kg) × (1.23 for men or 1.04 for women)] ÷ creatinine (µmol/L).
  • Use actual body weight (or adjusted weight in obesity) per local guidance.
• Drugs often needing adjustment or avoidance — DOACs, LMWH, metformin, SGLT2 inhibitors (glucose-lowering effect), sulphonylureas (hypoglycaemia), gabapentin and pregabalin, morphine and codeine (use oxycodone or alfentanil in severe CKD — specialist), nitrofurantoin (avoid if eGFR under 45, short courses down to 30), trimethoprim (raises potassium), digoxin, lithium, allopurinol, aciclovir, NSAIDs (avoid).
• AKI sick day rules — temporarily stop certain drugs during dehydrating illness (vomiting, diarrhoea, fever): Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors ("SADMANS") — restart 24–48 hours after eating and drinking normally.

Polypharmacy

• Polypharmacy — usually defined as 5 or more regular medicines; "problematic polypharmacy" is when medicines are inappropriate or their combined harm outweighs benefit. ("Appropriate polypharmacy" — many medicines, each justified — also exists.)
• How common — many people over 75 take 10 or more medicines.
• Why it happens — single-disease guidelines applied to people with many diseases, prescribing cascades, medicines never reviewed or stopped, several prescribers, hospital and specialist additions, patient expectations.
• Harms — adverse drug reactions, interactions, falls, delirium, AKI, hospital admissions, poor adherence, pill burden, cost.
• Particularly risky combinations:
  • "Triple whammy" — ACE inhibitor or ARB + diuretic + NSAID → AKI.
  • Anticoagulant or antiplatelet + NSAID or SSRI → GI bleeding.
  • Multiple sedatives (opioid + benzodiazepine + gabapentinoid) → respiratory depression, falls.
  • Multiple QT-prolonging drugs (citalopram, macrolides, antipsychotics, ondansetron, methadone).
  • Several drugs raising potassium (ACE inhibitor, spironolactone, trimethoprim, potassium supplements).
  • Several anticholinergics together.
• NICE NG56 (multimorbidity) — consider an approach to care that takes account of multimorbidity: identify goals, review medicines and treatments with limited benefit, and agree an individualised plan.

Adverse Drug Reactions and Prescribing Cascades

• Any new symptom in an older person could be a drug side effect — always review the drug chart.
• Common adverse drug reactions leading to admission — bleeding (anticoagulants, antiplatelets, NSAIDs), AKI (diuretics, ACE inhibitors, NSAIDs), falls and fractures (sedatives, antihypertensives), hypoglycaemia (insulin, sulphonylureas), hyponatraemia (thiazides, SSRIs, carbamazepine, PPIs), hyperkalaemia, constipation (opioids, anticholinergics, iron, calcium), delirium, bradycardia (beta-blockers, digoxin, donepezil), C. difficile (antibiotics, PPIs).
• Prescribing cascade — a drug side effect is mistaken for a new condition and treated with another drug. Examples:

  First drug	Side effect	Second drug added
  Amlodipine (calcium channel blocker)	Ankle swelling	Furosemide → falls, AKI, incontinence
  Donepezil	Urinary incontinence	Oxybutynin → worsening confusion
  Antipsychotic or metoclopramide	Parkinsonism	Levodopa
  NSAID	Raised BP	Antihypertensive
  Thiazide	Gout	Allopurinol and colchicine
  ACE inhibitor	Cough	Cough linctus or antibiotics
  Opioid	Constipation and nausea	Laxatives and antiemetics (appropriate if anticipated — but review the opioid)
  Alpha-blocker	Dizziness	Prochlorperazine or betahistine

• Report suspected adverse reactions via the MHRA Yellow Card scheme.

STOPP/START and Other Tools

• STOPP/START criteria (version 3, 2023) — evidence-based lists for people aged 65 and over:
  • STOPP (Screening Tool of Older Persons' Prescriptions) — potentially inappropriate medicines to stop. Examples:
    • Any drug without an evidence-based indication, or beyond the recommended duration.
    • Benzodiazepines and Z-drugs (falls, confusion) — especially for over 4 weeks.
    • Anticholinergics in dementia, delirium or constipation.
    • NSAIDs with eGFR under 50, heart failure, uncontrolled hypertension, or with anticoagulants without PPI.
    • Aspirin for primary prevention.
    • PPIs at full dose for over 8 weeks for uncomplicated peptic ulcer or oesophagitis.
    • Duplicate drug classes (two NSAIDs, two opioids, two antidepressants).
    • Antipsychotics for behavioural symptoms of dementia without clear need, or in Parkinson's disease.
    • Sulphonylureas with long duration of action (glibenclamide) — hypoglycaemia.
  • START (Screening Tool to Alert to Right Treatment) — potentially beneficial medicines omitted. Examples:
    • Anticoagulation in AF (unless contraindicated).
    • Bone protection after fragility fracture or with long-term steroids.
    • Laxatives with regular opioids.
    • ACE inhibitor in heart failure with reduced EF; statin in established CVD (unless end of life).
    • Vitamin D in housebound people or after falls.
    • Vaccines (influenza, pneumococcal).
• Beers Criteria (American Geriatrics Society) — US list of potentially inappropriate medicines.
• Other tools — anticholinergic burden scales, the STOPPFrail criteria (for people with limited life expectancy — e.g. stopping statins, osteoporosis drugs, tight diabetes and BP control), the NHS Scotland Polypharmacy Guidance (7 steps).
• Tools support, but don't replace, clinical judgement and discussion with the patient.

Anticholinergic Burden

• Anticholinergic drugs block acetylcholine — many drugs have this effect, and the effects add up (cumulative "anticholinergic burden").
• Side effects — "can't see, can't pee, can't spit, can't poo, can't think": blurred vision, urinary retention, dry mouth, constipation, confusion and delirium, falls, tachycardia, reduced sweating (heat stroke); long-term use is linked with cognitive decline and dementia.
• Common culprits:
  • Bladder — oxybutynin (worst — crosses into the brain), tolterodine, solifenacin (mirabegron is not anticholinergic).
  • Antidepressants — amitriptyline, nortriptyline, imipramine, paroxetine.
  • Antihistamines — chlorphenamine, promethazine, hydroxyzine, diphenhydramine (sleep aids).
  • Antipsychotics — chlorpromazine, olanzapine, quetiapine, clozapine.
  • Antiemetics and vertigo drugs — prochlorperazine, cyclizine, hyoscine.
  • Antispasmodics — hyoscine butylbromide; antiparkinsonian — procyclidine, trihexyphenidyl.
  • Others — carbamazepine, codeine (mild), loperamide (mild), ranitidine-like drugs.
• Scales — Anticholinergic Cognitive Burden (ACB) scale (each drug scores 1–3; a total of 3 or more is linked with cognitive impairment and higher mortality), Anticholinergic Effect on Cognition (AEC) scale.
• Action — reduce the total burden; switch to alternatives (e.g. sertraline instead of amitriptyline, mirabegron or bladder training instead of oxybutynin, loratadine instead of chlorphenamine).
• Avoid anticholinergics with acetylcholinesterase inhibitors (they cancel each other out).

Deprescribing

• Deprescribing — the planned, supervised process of stopping or reducing medicines that may no longer be beneficial or may be causing harm — a positive clinical intervention, not "withdrawing care".
• When to consider — falls, delirium, frailty, new symptoms, limited life expectancy, multiple medicines, adverse effects, treatment burden, changes in goals (e.g. end of life), care home admission.
• Steps (e.g. NHS Scotland 7 steps):
  1. Aims — what matters to the patient?
  2. Need — identify essential drugs (e.g. thyroxine, anticonvulsants, insulin in type 1).
  3. Need — does the patient take unnecessary drugs (no indication, indication resolved)?
  4. Effectiveness — are therapeutic objectives being met?
  5. Safety — are there adverse effects, interactions, or high-risk drugs?
  6. Cost-effectiveness.
  7. Patient-centred — is the patient willing and able to take the medicines as intended?
• How to stop safely:
  • One drug at a time, so effects can be monitored.
  • Taper drugs that cause withdrawal or rebound — benzodiazepines, antidepressants, antipsychotics, beta-blockers, steroids, gabapentinoids, opioids, PPIs (rebound acid), clonidine.
  • Monitor for return of symptoms; agree a plan if symptoms return.
  • Communicate the change (GP, care home, pharmacy, patient and family) and document why.
• Common deprescribing targets — sedatives and hypnotics, anticholinergics, antipsychotics in dementia, PPIs without ongoing indication, aspirin for primary prevention, statins near the end of life, intensive BP and glucose control in frailty, bisphosphonates after 5–10 years (review), vitamins and supplements without indication, duplicate drugs.

Medication Review, Adherence and Transitions

• Structured medication review — a person-centred review of all medicines (prescribed and bought), with the patient, focused on effectiveness, safety and goals — offered to people with polypharmacy, frailty, care home residents and those on high-risk drugs (NICE NG5).
• Adherence — about a third to half of medicines for long-term conditions are not taken as prescribed:
  • Unintentional — forgetting, confusion, poor vision, swallowing problems, can't open packaging, complex regimens.
  • Intentional — side effects, beliefs, costs, not seeing benefit.
  • Solutions — simplify regimens (once daily, combine doses), explain purpose, large-print labels, easy-open tops, reminder charts, liquid or dispersible forms, carers' support.
  • Multi-compartment compliance aids ("dosette boxes", blister packs) — not routinely recommended (Royal Pharmaceutical Society) — they don't suit all drugs, reduce flexibility and increase errors at changes; use only after an individual assessment.
• Transitions of care (admission, discharge, care home moves) are high-risk times for errors:
  • Medicines reconciliation within 24 hours of admission (two sources — GP record, patient's own drugs, Summary Care Record).
  • Discharge letter — clearly list changes, reasons, and what to monitor (e.g. "Stopped bendroflumethiazide — hyponatraemia").
  • Discharge Medicines Service — community pharmacies follow up high-risk patients after discharge.
• Time-critical medicines — Parkinson's drugs, insulin, anticonvulsants, antibiotics in sepsis — must be given on time in hospital.

Anticoagulation and Antiplatelets

• Atrial fibrillation — stroke risk rises steeply with age; most older people with AF benefit from anticoagulation (NICE NG196 — CHA₂DS₂-VASc; ORBIT for bleeding risk).
• Falls are rarely a reason to withhold anticoagulation — modelling suggests a person would need to fall very frequently (around 300 times a year) for the risk of subdural haemorrhage to outweigh the stroke benefit; manage falls risk instead.
• Age alone is not a contraindication; aspirin is not an alternative for stroke prevention in AF (similar bleeding, little benefit).
• DOACs (apixaban, edoxaban, rivaroxaban, dabigatran) — generally preferred to warfarin:
  • Dose by creatinine clearance (Cockcroft–Gault), age and weight — under-dosing (common) increases strokes; over-dosing increases bleeding.
  • Apixaban dose reduction — 2 of 3: age 80 or over, weight 60 kg or less, creatinine 133 µmol/L or more.
  • Dabigatran — avoid in significant kidney impairment (mostly renally cleared); capsules can't be opened.
  • Check kidney function at least annually (more often if CrCl under 60 or frail).
• Warfarin — mechanical valves, antiphospholipid syndrome; many interactions (antibiotics), INR monitoring.
• Reduce bleeding risk — avoid NSAIDs and unnecessary antiplatelets alongside anticoagulants (no aspirin with DOAC for stable coronary disease after 12 months — follow cardiology advice), PPI if high GI risk, control BP, limit alcohol.
• Antiplatelets — no aspirin for primary prevention; secondary prevention after stroke (clopidogrel) or MI is still beneficial at older ages; review dual antiplatelet duration.
• VTE prophylaxis — assess in hospital; reduce LMWH dose in severe kidney impairment.

Blood Pressure, Statins and Heart Drugs

• Hypertension (NICE NG136):
  • Treat people over 80 with stage 2 hypertension (BP 160/100 or more) — benefit shown even in the very old (HYVET).
  • Target — clinic BP under 150/90 for people aged 80 and over (and home under 145/85); use clinical judgement in frailty or multimorbidity.
  • Measure standing BP in people with symptoms of postural hypotension, and base targets on standing BP if orthostatic hypotension is present.
  • Lower BP may be harmful in frail people (falls, AKI, cognitive impairment) — deprescribe if BP is low or postural symptoms occur.
• Statins:
  • Secondary prevention — beneficial at older ages.
  • Primary prevention over 75 — may be offered (e.g. atorvastatin 20 mg) after discussion; benefits take years — less relevant with limited life expectancy (NICE NG238).
  • Stop near the end of life — stopping statins in people with limited life expectancy is safe and may improve quality of life.
  • Muscle aches — check CK; interactions (clarithromycin, amlodipine with simvastatin).
• Heart failure — guideline therapies still help older people; titrate carefully (BP, kidney function, potassium); SGLT2 inhibitors (dehydration, genital infection); loop diuretics (dehydration, incontinence — adjust timing).
• Digoxin — narrow therapeutic index; toxicity in kidney impairment, hypokalaemia, dehydration — nausea, confusion, yellow-green vision, bradycardia, arrhythmias.
• Rate control — beta-blockers and calcium channel blockers cause bradycardia and falls; review if HR under 60.

Diabetes in Frailty

• Hypoglycaemia is more dangerous than modest hyperglycaemia in frail older people — falls, fractures, arrhythmias, delirium, cognitive decline; symptoms may be atypical (confusion, falls, drowsiness).
• Relax targets — individualise HbA1c (e.g. around 58–64 mmol/mol in frail people, and higher with severe frailty or end of life); the aim is to avoid hypoglycaemia and symptomatic hyperglycaemia (thirst, polyuria, infections, dehydration).
• Deprescribe — if HbA1c is low (e.g. under 53 mmol/mol on insulin or sulphonylureas), reduce or stop these drugs.
• Drug choices:
  • Metformin — low hypoglycaemia risk; reduce if eGFR under 45, stop under 30; GI effects, weight loss, B12 deficiency.
  • DPP-4 inhibitors (gliptins — linagliptin needs no kidney dose change) — safe, well tolerated.
  • Sulphonylureas (gliclazide) — hypoglycaemia risk; avoid long-acting glibenclamide.
  • SGLT2 inhibitors — dehydration, genital infections, euglycaemic DKA, weight loss (undesirable in frailty); sick day rules.
  • Insulin — simplify (once-daily basal insulin); who will give it?; avoid complex regimens.
• End of life — minimal monitoring, stop most drugs, aim for comfort (Diabetes UK end-of-life guidance).

Pain Relief

• Pain is under-recognised and under-treated in older people, especially with dementia — use observational tools (Abbey Pain Scale, PAINAD).
• Paracetamol — first-line for many types of pain; reduce dose in low body weight (under 50 kg) or liver risk factors (e.g. 500 mg–1 g up to 3 g a day per local guidance).
• NSAIDs — avoid or use with great care — GI bleeding, AKI, heart failure, hypertension; topical NSAIDs are safer (osteoarthritis).
• Opioids:
  • Start low (e.g. morphine 1.25–2.5 mg) and titrate; regular laxatives; monitor for confusion, sedation, falls, constipation, retention, respiratory depression.
  • Codeine and tramadol — unpredictable (genetic metabolism), tramadol lowers seizure threshold, causes hyponatraemia, serotonin syndrome with SSRIs — not ideal in older people.
  • Kidney impairment — morphine metabolites accumulate (drowsiness, myoclonus) — consider oxycodone, or alfentanil or fentanyl in severe CKD (specialist).
  • Patches (buprenorphine, fentanyl) — for stable pain; not for opioid-naïve or acute pain; check skin, heat increases absorption.
• Neuropathic pain — amitriptyline (anticholinergic — use low dose cautiously or avoid), duloxetine, gabapentin or pregabalin (dizziness, sedation, falls; reduce in CKD; misuse potential; respiratory depression with opioids).
• Non-drug — physiotherapy, heat, TENS, activity pacing, psychological approaches.

Psychotropics and Hypnotics

• Benzodiazepines and Z-drugs (zopiclone, zolpidem):
  • Cause falls and hip fractures, confusion, daytime sedation, dependence, road traffic accidents; little benefit for sleep long-term.
  • Avoid starting; if long-term — slow taper (e.g. reduce by 10–25% every 2–4 weeks), with support; CBT for insomnia.
• Insomnia in older people — sleep naturally becomes lighter and shorter; look for causes (pain, nocturia, depression, sleep apnoea, restless legs, caffeine, daytime napping); sleep hygiene, CBT-I; melatonin (modified-release, 55 and over — short-term).
• Antidepressants — SSRIs (sertraline) — hyponatraemia (check sodium), bleeding (with NSAIDs, anticoagulants), falls; citalopram max 20 mg over 65 (QT); avoid tricyclics; mirtazapine (sedation, weight gain).
• Antipsychotics — stroke and mortality risk in dementia; parkinsonism, falls, QT, sedation, metabolic effects; review regularly and deprescribe where possible (see page 3).
• Lithium — toxicity with dehydration, ACE inhibitors, diuretics, NSAIDs; lower target levels in older people; kidney and thyroid monitoring.
• Antiepileptics — falls, sedation, hyponatraemia (carbamazepine, oxcarbazepine), osteoporosis (enzyme inducers), many interactions; levetiracetam and lamotrigine are often better tolerated.

PPIs, Laxatives and Other Common Drugs

• Proton pump inhibitors — often continued without indication; long-term risks — C. difficile, pneumonia, hypomagnesaemia, hyponatraemia, B12 deficiency, fractures, microscopic colitis; review and step down (lowest dose, on-demand, stop) unless ongoing indication (e.g. Barrett's, high bleeding risk on NSAIDs or anticoagulants plus antiplatelets).
• Laxatives — prescribe with opioids; avoid bulk-forming laxatives in immobile people with poor fluid intake (impaction); osmotic (macrogol) or stimulant (senna) are usually best.
• Diuretics — dehydration, AKI, hyponatraemia (thiazides), hypokalaemia, gout, urinary urgency and incontinence (adjust timing); review indication.
• Antibiotics — C. difficile (clindamycin, cephalosporins, co-amoxiclav, quinolones); fluoroquinolones — tendon rupture, aortic aneurysm, delirium, QT (MHRA restrictions); nitrofurantoin — lung and liver toxicity with long-term use; trimethoprim — hyperkalaemia; clarithromycin interactions (statins, colchicine, DOACs).
• Bisphosphonates — take upright with water on an empty stomach; review after 5 years (oral) or 3 years (IV).
• Vitamin D and calcium — calcium supplements cause constipation; review need.
• Eye drops — timolol (beta-blocker drops) can cause bradycardia and bronchospasm.
• Over-the-counter — sedating antihistamines (sleep aids), NSAIDs, codeine products, herbal remedies (St John's wort interactions).

Care Homes and Covert Medication

• Care home residents take many medicines and are frail — regular structured medication reviews by GPs and pharmacists (Enhanced Health in Care Homes).
• Swallowing difficulties — ask pharmacy about liquids, dispersible tablets or patches; crushing tablets may be unlicensed or unsafe (modified-release, enteric-coated, cytotoxic) — check with a pharmacist; review whether each medicine is still needed.
• Covert medication — giving medicines hidden in food or drink without the person's knowledge:
  • Only for people who lack capacity to make decisions about their medicines (Mental Capacity Act) and refuse them.
  • Only when it is in their best interests, agreed at a best interests meeting (prescriber, care staff, pharmacist, family or LPA, advocate).
  • The pharmacist advises on how to give each medicine safely (e.g. mixing with food).
  • Document the decision, list which medicines, and review regularly; minimise to essential medicines only.
  • Never for people with capacity who refuse; may form part of a deprivation of liberty (DoLS) (NICE SC1, CQC guidance).
• Antipsychotics in care homes — audit and reduce inappropriate use (national programmes).

Drugs to Watch in Older People

Spot the Diagnosis

Exam-style Scenarios

1. An 86-year-old woman (CFS 6) is admitted after a fall. She takes: amlodipine 10 mg, ramipril 10 mg, indapamide, doxazosin, atorvastatin, aspirin 75 mg (no history of vascular disease), omeprazole 40 mg (started 6 years ago for dyspepsia), amitriptyline 25 mg (sleep), zopiclone, oxybutynin and gliclazide (HbA1c 49). Standing BP 106/60.
Answer: Problematic polypharmacy contributing to falls.

• Stop or reduce — doxazosin and indapamide (orthostatic hypotension), aspirin (primary prevention), gliclazide (HbA1c low — hypoglycaemia risk), oxybutynin and amitriptyline (anticholinergic), taper zopiclone; step down omeprazole.
• Review BP after changes (target standing BP, relaxed); consider whether atorvastatin is still wanted.
• Do it one or two drugs at a time with a clear plan, discuss with the patient, and communicate changes and reasons to the GP and pharmacy.

2. An 84-year-old man with AF (CHA₂DS₂-VASc 5) has had three falls this year. His GP stopped his apixaban "because of the falls". Weight 58 kg, creatinine 118.
Answer: Inappropriate withdrawal of anticoagulation.

• Falls alone are rarely a reason to stop anticoagulation — stroke risk is high; discuss restarting.
• Apixaban 2.5 mg twice daily (age over 80 and weight under 60 kg); check creatinine clearance.
• Address the falls — multifactorial assessment, medication review, strength and balance; avoid NSAIDs and antiplatelets.

3. An 80-year-old woman with dementia is admitted with delirium. Her medicines include oxybutynin, chlorphenamine, amitriptyline and donepezil.
Answer: High anticholinergic burden contributing to delirium and counteracting donepezil.

• Calculate ACB score (high); stop oxybutynin (consider bladder training or mirabegron), chlorphenamine (non-sedating antihistamine if needed), taper amitriptyline.
• Look for other causes of delirium; continue donepezil (check pulse).
• Explain changes to family and GP.

4. A 91-year-old care home resident with advanced dementia (CFS 8) takes 12 medicines, including atorvastatin, alendronic acid, ramipril, metformin and a calcium supplement. She is losing weight and struggling to swallow tablets.
Answer: Deprescribing at the end of life.

• Use STOPPFrail — stop statin, alendronic acid, calcium, metformin (weight loss — check glucose), and reduce antihypertensives if BP allows.
• Keep medicines for symptom control (analgesia, laxatives); ask the pharmacist about liquid or alternative forms for the essentials.
• Discuss with the family or LPA, document best-interests decisions, and agree an advance care plan.

5. A 77-year-old man has taken temazepam 20 mg nightly for 15 years. He has had two falls and wants to stop.
Answer: Benzodiazepine deprescribing.

• Explain benefits (fewer falls, better cognition) and possible withdrawal symptoms; agree a slow taper (e.g. reduce by about 10–25% every 2–4 weeks, slower at the end), possibly switching to diazepam for easier tapering.
• Offer CBT for insomnia and sleep hygiene; treat contributors (nocturia, pain, low mood).
• Regular review; don't stop abruptly (risk of seizures and severe withdrawal).

Key Points

• Adverse drug reactions cause about 1 in 10 emergency admissions in older people — any new symptom may be a drug effect.
• Kidney function is the key pharmacokinetic change; use Cockcroft–Gault for DOACs and narrow therapeutic index drugs.
• Start low, go slow — but reach effective doses where worthwhile.
• Watch for prescribing cascades.
• STOPP/START — stop inappropriate drugs and start beneficial omitted ones; STOPPFrail at the end of life.
• Reduce anticholinergic burden — ACB 3 or more is linked with confusion and mortality.
• Deprescribe one drug at a time; taper drugs with withdrawal effects; communicate changes.
• Falls are rarely a reason to stop anticoagulation; dose DOACs correctly.
• No aspirin for primary prevention.
• BP target under 150/90 over 80; use standing BP and clinical judgement in frailty.
• In frailty, avoid hypoglycaemia — relax HbA1c targets and stop sulphonylureas or insulin if over-treated.
• Avoid NSAIDs, codeine, tramadol and benzodiazepines where possible.
• Thiazides and SSRIs cause hyponatraemia; long-term PPIs have real harms.
• Compliance aids are not a routine answer to adherence problems.
• Covert medication — only if lacking capacity, in best interests, with pharmacist advice and regular review.

Guidelines and Further Reading

• O'Mahony D et al.: STOPP/START criteria version 3 (2023); STOPPFrail version 2
• American Geriatrics Society: Beers Criteria for potentially inappropriate medication use in older adults
• NICE NG5: Medicines optimisation; NICE NG56: Multimorbidity
• NHS Scotland: Polypharmacy guidance — realistic prescribing (7 steps)
• Anticholinergic Burden Calculator (ACB scale) resources
• NICE NG196: Atrial fibrillation; NICE NG136: Hypertension in adults; NICE NG238: Cardiovascular disease — risk assessment and reduction
• Diabetes UK / TREND: Managing diabetes in frail older adults; End of life diabetes care
• Royal Pharmaceutical Society: Improving patient outcomes — the better use of multi-compartment compliance aids
• NICE SC1: Managing medicines in care homes (covert administration)
• MHRA: Yellow Card scheme; Drug Safety Updates (fluoroquinolones, DOAC dosing)
• BNF — for current doses